Policy Terms and Conditions

1.

from the medical council of any state of India and is thereby entitled to practice
medicine within its jurisdiction; and is acting within the scope and jurisdiction of
his license. The term Medical Practitioner includes a physician and / or surgeon.

Definitions

For the purposes of interpretation and understanding of the product the Company has
defined, herein below some of the important words used in the product and for the
remaining language and the words the Company believes to mean the normal meaning of
the English language as explained in the standard language dictionaries. The words and
expressions defined in the Insurance Act, IRDA Act, Regulations notified by the Authority
and Circulars and Guidelines issued by the Authority shall carry the meanings explained
therein. The judicial pronouncements of the highest courts in India will have the effect on
the definitions and the language used in this product. The Terms and Conditions, coverage's
and exclusions, benefits, various procedures and concepts which have been built in to the
product also carry the specified meaning assigned to them in the said language.
The terms defined below have the meanings ascribed to them wherever they appear in this
Policy and, where appropriate, references to the singular include references to the plural;
references to the male include the female and references to any statutory enactment
include subsequent changes to the same and vice versa.

1.13

Network Hospitals (Network Provider) means Hospitals or other

health care providers enlisted by the Company, to provide medical services to the
Insured Person on payment by a cashless facility. The list is available with the
Company and subject to amendment from time to time.

1.14

Nominee means the person named in the Policy Certificate who is nominated
to receive the benefits under this Policy in accordance with the terms of the
Policy, if the Policyholder is deceased.

1.15

Notification of Claim (Intimation) is the process of notifying a claim to

the insurer or TPA by specifying the timelines as well as the address/telephone
number to which it should be notified.

1.16

Policy means these Policy Terms & Conditions, Specific Policy Conditions, Addon Benefits (if any),the Proposal Form, Policy Certificate and Annexures which
form part of the policy contract and shall be read together.

1.17

Policy Certificate means the certificate attached to and forming part of

this Policy.

1.1

Accident/Accidental means a sudden, unforeseen and involuntary event

caused by external and visible means.

1.2

Age means the completed age (in years) of the Insured Person as on his last birthday.

1.3

Company means Religare Health Insurance Company Limited

1.18

1.4

Disclosure to Information Norm means the Policy shall be void and all
premium paid hereon shall be forfeited to the Company, in the event of
misrepresentation, mis-description or non-disclosure of any material fact.

Policyholder means the person named in the Policy Certificate as the

Policyholder.

1.19

Policy Period means the period commencing from the Policy Period Start
Date and ending on the Policy Period End Date as specified in the Policy
Certificate.

1.20

Policy Period End Date means the date on which the Policy expires, as
specified in the Policy Certificate.

1.21

Policy Period Start Date means the date on which the Policy commences,
as specified in the Policy Certificate.

1.22

Portability means the right accorded to an individual health insurance

Policyholder (including family cover) to transfer the credit gained by the Insured
Person for pre-existing conditions and time bound exclusions if the Policyholder
chooses to switch from one insurer to another insurer or from one plan to
another plan of the Company, provided the previous Policy has been maintained
without any break.

1.23

Pre-existing Disease means any condition, ailment or Injury or related

condition for which the Insured Person had signs or symptoms, and/or were
diagnosed, and/or received medical advice/treatment within 48 months prior to
the first Policy issued by the Company.

1.24

Reasonable Charges means the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the prevailing
charges in the geographical area for identical or similar services, taking into
account the nature of the Illness / Injury involved.

1.25

Renewal defines the terms on which the contract of insurance can be renewed
on mutual consent with a provision of Grace Period for treating the Renewal
continuous for the purpose of all waiting periods.

1.26

Sum Insured means the amount specified against each Insured Person in the
Policy Certificate which represents the Company's maximum, total and
cumulative liability for that Insured Person for any and all claims incurred in
respect of that Insured Person during the Policy Period.

1.27

Surgical Procedure means manual and / or operative procedure required

for treatment of an Illness or Injury, correction of deformities and defects,
diagnosis and cure of diseases, relief of suffering or prolongation of life,
performed in a Hospital or a day care centre by a Medical Practitioner.

Benefits

1.5

1.6

1.7

Grace Period means the specified period of time immediately following the
premium due date during which payment can be made to renew or continue a
Policy in force without loss of continuity benefits such as waiting periods and
coverage of Pre-existing Diseases. Coverage is not available for the period for
which no premium is received.
Hazardous Activities means any sport or activity, which is potentially
dangerous to the Insured Person whether he is trained or not. Such sport/activity
includes stunt activities of any kind, adventure racing, base jumping, biathlon, big
game hunting, black water rafting, BMX stunt/obstacle riding, bobsleighing/using
skeletons, bouldering, boxing, canyoning, cavin/pot holing, cave tubing, rock
climbing/trekking/mountaineering, cycle racing, cyclo cross, drag racing,
endurance testing, hand gliding, harness racing, hell skiing, high diving (above 5
meters), hunting, ice hockey, ice speedway, jousting, judo, karate, kendo, lugging,
risky manual labor, marathon running, martial arts, micro - lighting, modern
pentathlon, motor cycle racing, motor rallying, parachuting, paragliding/
parapenting, piloting aircraft, polo, power lifting, power boat racing, quad biking,
river boarding, scuba diving, river bugging, rodeo, roller hockey, rugby, ski
acrobatics, ski doo, ski jumping, ski racing, sky diving, small bore target shooting,
speed trials/time trials, triathlon, water ski jumping, weight lifting or wrestling of
any type.
Hospital means any institution established for In-patient Care and Day Care
Treatment of Illness and/or Injuries and which has been registered as a Hospital
with the local authorities, wherever applicable, and is under the supervision of a
registered and qualified Medical Practitioner AND must comply with all minimum
criteria as under :

(a)

has at least 10 in-patient beds, in those towns having a population of less

than 10,00,000 and 15 in-patient beds in all other places;

(b)

has qualified nursing staff under its employment round the clock;

(c)

has qualified Medical Practitioner in-charge round the clock;

(d)

has a fully equipped operation theatre of its own, where Surgical Procedures are
carried out;

(e)

maintains daily records of patients and will make these accessible to the
Company's authorized personnel.

2.

1.8

Hospitalization means admission in a Hospital for a minimum period of 24

In-patient Care consecutive hours except for specified procedures / treatments,
where such admission could be for a period of less than 24consecutive hours.

(a)

Any Benefit shall be available only if the same is specifically mentioned in

the Policy Certificate.

(b)

Admissibility of a claim under Benefit 1 or Benefit 2 is a pre-condition to the

admission of a claim for Benefit 3 and the event giving rise to the
claim under the Benefit 1 or Benefit 2 shall be within the Policy Period for the
claim for such Benefit to be accepted.

(c)

The maximum, total and cumulative liability of the Company for an

Insured Person for any and all claims incurred under this Policy during the Policy
Period in relation to any Insured Person shall not exceed the Sum Insured for that
Insured Person. All claims shall be payable subject to the terms, conditions and
exclusions of the Policy and subject to availability of the Sum Insured.

(d)

Benefit 1 and Benefit 2 are mutually exclusive.

1.9

Illness means a sickness or a disease or a pathological condition leading to the

impairment of normal physiological function which manifests itself during the
Policy Period and requires medical treatment.

1.10

Injury means accidental physical bodily harm excluding Illness or disease solely
and directly caused by external, violent and visible and evident means which is
verified and certified by a Medical Practitioner.

1.11

Insured Person (Insured) means a person whose name specifically

appears under Insured in the Policy Certificate and with respect to whom the
premium has been received by the Company.

1.12

Medical Practitioner means a person who holds a valid registration

General Conditions applicable to all Benefits:

2.1

Benefit 1 : Critical Illness, Medical Events & Surgical Procedures

(a)

If, during the Policy Period, an Insured Person:

(i)

is diagnosed to be suffering from a Critical Illness or a Critical Illness

manifests in that Insured Person; or

(ii)

undergoes any Covered Surgical Procedure; or

(iii)

suffers from any of the Covered Medical Events,

(D)

(II)

the Company will pay the Sum Insured as specified in the Policy Certificate against
this Benefit.
(b)

(c)

In case any claim is admissible under this Benefit, coverage under the Policy for
that Insured Person shall immediately and automatically terminate. However,
other Insured Persons (if any) under this Policy shall continue to be covered under
this Benefit.
For the purpose of this Benefit, Critical Illness means the following illnesses and
diseases to the extent described below only:
(i)

(v)

Cancer
(I)

(II)

The term cancer includes leukemia, lymphoma and sarcoma.

(III)

The following are excluded:

(A)

(ii)

(II)
(iv)

Granulomas;

(C)

Vascular malformations;

(D)

Haematomas;

(E)

Calcification;

(F)

Meningiomas;

(G)

Tumours of the pituitary gland or spinal cord; and

(H)

Tumours of acoustic nerve (acoustic neuroma)

The unequivocal diagnosis of progressive degenerative idiopathic

Parkinson's Disease by a consultant neurologist.
This diagnosis must be supported by all of the following conditions:
The disease cannot be controlled with medication

(B)

Signs of progressive impairment

(C)

Inability of the Insured Person to perform (whether aided or

unaided) at least 3 of the following 5 Activities of Daily
Living for a continuous period of at least 6 months .

Activities of Daily Living:

(A)

Transfer: Getting in and out of bed without requiring

external physical assistance.

(B)

Any skin cancer other than invasive malignant melanoma;

(C)

All tumours of the prostate unless histologically classified as

having a Gleason score greater than 6 or having progressed to
at least clinical TNM classification T2N0M0;

(B)

Mobility: The ability to move from one room to another

without requiring any external physical assistance.

(C)

(D)

Papillary micro - carcinoma of the thyroid less than 1 cm in

diameter;

Dressing: Putting on and taking of all necessary items of

clothing without requiring any external physical assistance.

(D)

(E)

Chronic lymphocyctic leukaemia less than RAI stage 3;

Bathing/Washing: The ability to wash in the bath or shower

(including getting in and out of the bath or shower) or wash
by other means.

(E)

Eating: All tasks of getting food into the body once it has been
prepared.

(F)

Microcarcinoma of the bladder;

(G)

All tumours in the presence of HIV infection.

End stage renal disease presenting as chronic irreversible failure of

both kidneys to function, as a result of which either regular renal
dialysis (hemodialysis or peritoneal dialysis) is instituted or renal
transplantation is carried out. Diagnosis has to be confirmed by a
consultant physician.

The definite occurrence of multiple sclerosis. The diagnosis must be

supported by all of the following:
(A)

Investigations including typical MRI and CSF findings, which

unequivocally confirm the diagnosis to be multiple sclerosis;

(B)

There must be current clinical impairment of motor or

sensory function, which must have persisted for a continuous
period of at least 6 months; and

(C)

Well documented clinical history of exacerbations and

remissions of said symptoms or neurological deficits with at
least two clinically documented episodes at least one month
apart.

Other causes of neurological damage such as SLE and HIV are

excluded.

Benign Brain Tumor

(I)

(III)

Carcinoma in situ of breasts, Cervical dysplasia CIN-1,

CIN -2 & CIN-3;

(IV) Parkinson's disease secondary to drug and/or alcohol abuse is

excluded.
(vi)

Alzheimer's Disease
(I)

Alzheimer's (presenile dementia) disease is a progressive

degenerative disease of the brain characterised by diffuse atrophy
throughout the cerebral cortex with distinctive histopathologic
changes.

(II)

Deterioration or loss of intellectual capacity as confirmed by clinical

evaluation and imaging tests, arising from Alzheimer's disease,
resulting in progressive significant reduction in mental and social
functioning requiring the continuous supervision of the Insured
Person. This diagnosis must be supported by the clinical confirmation
of an appropriate consultant neurologist and supported by the
Company's appointed doctor.

Multiple Sclerosis
(I)

Cysts;

(B)

(A)

End Stage Renal Failure

(I)

(iii)

(II)

Tumours showing the malignant changes of carcinoma in situ

and tumours which are histologically described as premalignant or non-invasive, including but not limited to:
a.

Exclusions :
(A)

Parkinson's Disease
(I)

A malignant tumour characterized by the uncontrolled growth

and spread of malignant cells with invasion and destruction of normal
tissues. This diagnosis must be supported by histological evidence of
malignancy and confirmed by a pathologist.

Its presence must be confirmed by a neurologist or

neurosurgeon and supported by findings on Magnetic
Resonance Imaging, Computerised Tomography, or other
reliable imaging techniques.

(III)

Exclusions :
(A)

Non organic diseases such as neurosis and psychiatric

illnesses;

(B)

Alcohol related brain damage;

(C)

Any other type of irreversible organic disorder/dementia;

(vii) End Stage Liver Disease

(I)

End stage liver disease resulting in cirrhosis and evidenced by all of

the following criteria:

A benign tumour in the brain where all of the following conditions

are met:

(A)

Permanent jaundice;

(A)

It is life threatening;

(B)

Uncontrollable ascites;

(B)

It has caused damage to the brain;

(C)

Hepatic encephalopathy;

(C)

It has undergone surgical removal or, if inoperable, has

caused a permanent neurological deficit such as but not
restricted to characteristic symptoms of increased
intracranial pressure such as papilloedema, mental
symptoms, seizures and sensory impairment; and

(D)

Oesophageal or Gastric Varices and portal hypertension;

(II)

Liver disease arising out of or secondary to alcohol or drug misuse is

excluded.

(viii) Motor Neurone Disorder

(I)

(ix)

Motor neurone disease diagnosed by a specialist Medical Practitioner

as spinal muscular atrophy, progressive bulbar palsy, amyotrophic
lateral sclerosis or primary lateral sclerosis. There must be
progressive degeneration of corticospinal tracts and anterior horn
cells or bulbar efferent neurons. There must be current significant
and permanent functional neurological impairment with objective
evidence of motor dysfunction that has persisted for a continuous
period of at least 3 months.

(II)

Arterial Blood Gas analysis with partial oxygen pressures of

55mmHg or less;

(I)

(C)

Dyspnoea at rest.

(II)

(e)

This diagnosis must be confirmed by a chest physician.

(II)

(II)

Angioplasty and/or any other intra-arterial procedures;

(B)

Any key-hole or laser surgery.

For the purpose of this Benefit, Covered Medical Events means occurrence
of any of the following Medical Events as more specifically described below
only, for the first time during the lifetime of the Insured Person :
(i)

The presence of bacterial infection in cerebrospinal fluid by

lumbar puncture;

(B)

A consultant neurologist.

Stroke
(I)

Any cerebrovascular incident producing permanent

neurological sequelae. This includes infarction of brain tissue,
thrombosis in an intra-cranial vessel, haemorrhage and
embolisation from an extracranial source. Diagnosis has to
be confirmed by a specialist Medical Practitioner and
evidenced by typical clinical symptoms as well as typical
findings in CT Scan or MRI of the brain.

(II)

Evidence of permanent neurological deficit lasting

for atleast 3 months has to be produced.

(III)

Bacterial Meningitis in the presence of HIV infection is

excluded.

Chronic persistent bone marrow failure which results in Anaemia,

Neutropenia and Thrombocytopenia requiring treatment with at
least one of the following:
(A)

Blood product transfusion;

(B)

Marrow stimulating agents;

(C)

Immunosuppressive agents; or

(D)

Bone marrow transplantation

The diagnosis must be confirmed by a hematologist using relevant

laboratory investigations including Bone Marrow Biopsy. Two out of
the following three values should be present:
(A)

Absolute Neutrophil count of 500 per cubic millimetre or

less;

(B)

Absolute Reticulocyte count of 20,000 per cubic millimetre

or less; and

(C)

Platelet count of 20,000 per cubic millimetre or less.

(ii)

(iii)

(I)

(B)
(II)

(II)

(III)

One of the following human organs: heart, lung, liver, kidney,

pancreas, that resulted from irreversible end-stage failure of
the relevant organ; or
Human bone marrow using haematopoietic stem cells.

(B)

Other stem-cell transplants;

Where only islets of langerhans are transplanted.

Heart Valve Replacement

The actual undergoing of open-heart valve surgery to replace or
repair one or more heart valves, as a consequence of defects in,
abnormalities of, or disease-affected cardiac valves. The diagnosis of

(v)

Vascular disease affecting only the eye or optic nerve

or vestibular functions.

A history of typical clinical symptoms consistent with the

diagnosis of Acute Myocardial Infarction (for e.g. typical chest
pain);

(B)

New characteristic electrocardiogram changes;

(C)

Elevation of infarction specific enzymes, Troponins or other

specific biochemical markers.

The following conditions are excluded:

Non-ST-segment elevation myocardial infarction (NSTEMI)
with elevation of Troponin I or T;

(B)

Other acute Coronary Syndromes;

(C)

Any type of angina pectoris.

Major Burns
(I)

Third degree (full thickness of the skin) burns covering at least 20%
of the surface of the Insured Person's body. The condition should be
confirmed by a consultant physician.

(II)

Burns arising due to self-infliction are excluded.

The following are excluded:

(A)

(I)

(iv)

(C)

The first occurrence of myocardial infarction which means the death

of a portion of the heart muscle as a result of inadequate blood
supply to the relevant area. The diagnosis for this will be evidenced
by all of the following criteria:

(A)

The undergoing of a transplant has to be confirmed by a specialist

Medical Practitioner.

Traumatic injury of the brain;

Total and irreversible loss of use of two or more limbs as a result of

Injury or disease of the brain or spinal cord. A specialist Medical
Practitioner must be of the opinion that the paralysis will be
permanent with no hope of recovery and must be present for more
than 3 months.

(A)

The actual undergoing of a transplant of:

(A)

Transient ischemic attacks (TIA);

(B)

Myocardial Infarction
(I)

Major Organ Transplant

The following are excluded:

(A)

Paralysis
(I)

For the purpose of this Benefit, Covered Surgical Procedures means undergoing
any of the following Surgical Procedures as more specifically described below
only, for the first time during the lifetime of the Insured Person :

(ii)

Excluded are:
(A)

Aplastic Anaemia
(I)

(i)

The actual undergoing of open chest surgery for the correction of

one or more coronary arteries, which is / are narrowed or blocked,
by Coronary Artery Bypass Graft (CABG). The diagnosis must be
supported by a coronary angiography and the realization of surgery
has to be confirmed by a specialist Medical Practitioner.

Bacterial infection resulting in severe inflammation of the

membranes of the brain or spinal cord resulting in significant,
irreversible and permanent neurological deficit. The neurological
deficit must persist for at least 6 weeks. This diagnosis must be
confirmed by:
(A)

Catheter based techniques including but not limited to,

balloon valvotomy/valvuloplasty.

Coronary Artery Bypass Graft

Bacterial Meningitis
(I)

(d)

(iii)

Requiring permanent oxygen therapy as a result of

a consistent FEV1 test value of less than one litre. (Forced
Expiratory Volume during the first second of a forced
exhalation);

(B)

Exclusions:
(A)

End Stage Respiratory Failure including Chronic Interstitial Lung

Disease. All of the following criteria must be met:
(A)

(xi)

(II)

End Stage Lung Disease

(I)

(x)

the valve abnormality must be supported by an echocardiography

and the realization of surgery has to be confirmed by a specialist
Medical Practitioner.

Coma
(I)

A state of unconsciousness with no reaction or response to external

stimuli or internal needs. This diagnosis must be supported by
evidence of all of the following:
(A)

No response to external stimuli continuously for at least 96

hours;

(II)

(vi)

(a)

Life support measures are necessary to sustain life;

(C)

Permanent neurological deficit which must be assessed at

least 30 days after the onset of the coma.

(c)

(d)

Benefit 2 : Personal Accident

(viii) The Second Opinion does not entitle the Insured Person to any
consultation from or further opinions from that Medical Practitioner.
(c)

The Insured Person's death within 12 months of the occurrence of

the Injury; or

(ii)

The Insured Person's Permanent Total Disablement within 12

months of the occurrence of the Injury such that the Insured Person
is unable to resume his normal occupation or engage in similar gainful
employment due to the Permanent Total Disability suffered,

In case any claim is admissible under this Benefit, coverage under the Policy
for that Insured Person shall immediately and automatically terminate.
However, other Insured Person shall continue to be covered under this
Policy.
If the Company has admitted a claim for Permanent Total Disablement,
then the Company shall not be liable to make any payment under the Policy
on the death of the Insured Person, if the Insured Person subsequently dies.

For the purposes of this Benefit only:

(i)

If the Insured Person suffers an Injury during the Policy Period solely and
directly due to an Accident that occurs during the Policy Period, which
directly results in:
(i)

The Policyholder or Insured Person shall indemnify the Company and hold
the Company harmless for any loss or damage caused by or arising out of or
in relation to any opinion, advise, prescription, actual or alleged errors,
omissions or representations made by the Medical Practitioner or for any
consequences of any action taken or not taken in reliance thereon.

(vii) Any Second Opinion provided under this Benefit shall not be valid for any
medico-legal purposes.

Total and irreversible loss of sight in both eyes as a result of Illness or

Accident. The blindness must be confirmed by an ophthalmologist.

(d)

Second Opinion means an additional medical opinion obtained by the

Company from a Medical Practitioner solely on the Policyholder or
Insured Person's express request in relation to a Critical Illness which
the Insured Person has been diagnosed with during the Policy Period.

Any claim under this Benefit can be made only at the Company's Network
Hospitals.

2.5

Benefit 5 : Health check-up

(a)

On the Insured Person's request, the Company shall arrange for the Insured
Person's Health Check-up in accordance with the table below at its Network
Hospitals, provided that:

(b)

This Benefit shall only be available once during the Policy Year.

Age/Sum Insured

Upto 10 Lac

10 Lac - 50 Lac

Above 50 Lac

Upto 45 years

Set 1

Set 2

Set 3

46 years to 55 years

Set 2

Set 3

Set 4

56 years & above

Set 3

Set 4

Set 5

For the purposes of this Benefit, Permanent Total Disablement means:

Set

List of Medical Tests

(i)

the total and irrecoverable loss of sight of both eyes; or

Set 1

(ii)

the actual loss by physical separation of both hands or both feet or

one entire hand and one entire foot; or

Complete Blood Count, Urine Routine, Blood Group, ESR, Fasting Blood
Glucose, S Cholesterol, SGPT, Creatinine

Set 2

(iii)

the total and irrecoverable loss of use of both hands or both feet or
of one hand and one foot without physical separation

Complete Blood Count, Urine Routine, Blood Group, ESR, Hb1Ac, ECG, S
Cholesterol, SGPT, Creatinine

Set 3

(e)

For the purposes of this Benefit, physical separation means as regards the
hand actual separation at or above the wrists, and as regards the foot actual
separation at or above the ankle.

Complete Blood Count, Urine Routine, Blood Group, ESR, Hb1Ac, ECG,
Lipid Profile, Kidney Function Test, Complete Physical Examination by
Physician

Set 4

Complete Blood Count, Urine Routine, Blood Group, ESR, Hb1Ac, Lipid
Profile, Stress Test (TMT) or 2D echo, Kidney Function Test, Liver Function
Test, Complete Physical Examination by Physician

Set 5

Complete Blood Count, Urine Routine, Blood Group, ESR, Hb1Ac, Lipid
Profile, Stress Test (TMT) or 2D echo, Kidney Function Test, Liver Function
Test, Pulmonary Function Test, Complete Physical Examination by Physician

(c)

It is agreed and understood that details in the table above, including the list of
medical tests is subject to review by the Company. The Company may revise or
modify the above with prior approval from IRDA. In case these details are
modified, the Policyholder shall be duly intimated at least three months prior to
the date of Renewal when such modification comes into effect.

(d)

Any claim under this Benefit can be made only at the Company's Network
Hospitals.

2.3

Benefit 3 : Child Education

(a)

If a claim for any event under Benefit 1 or Benefit 2 of the Policy has been
admitted, then in addition to any amount payable under that Benefit, the
Company will pay the amount specified in the Policy Certificate against this
Benefit, for the education of the Insured Person's child, provided that:
(i)

The child is less than Age 24 at the time of occurrence of the event; and

(ii)

Valid documentation establishing the relationship of the child with the

Insured Person and the Age of the child is submitted.

2.4

Benefit 4 : Second Opinion

(a)

If the Insured Person is diagnosed with any Critical Illness (as specified under
Benefit 1 of the Policy Terms & Conditions) during the Policy Period, then at the
Policyholder's / Insured Person's request, the Company shall arrange for a Second
Opinion from a Medical Practitioner at its own cost.

(b)

It is agreed and understood that the Second Opinion will be based only on the
information and documentation provided to the Company which will be shared
with the Medical Practitioner and is subject to the following:
(i)

This Benefit can be availed a maximum of one time by an Insured Person

during the Policy Year for each Critical Illness.

(ii)

The Insured Person is free to choose whether or not to obtain the Second
Opinion and, if obtained under this Benefit, then whether or not to act on it.

(iii)

This Benefit is for additional information purposes only and does not and
should not be deemed to substitute the Insured Person's visit or
consultation to an independent Medical Practitioner.

(iv)

The Company does not provide a Second Opinion or make any

representation as to the adequacy or accuracy of the same, the Insured
Person's or any other person's reliance on the same or the use to which the
Second Opinion is put.

(v)

(vi)

The condition has to be confirmed by a specialist Medical

Practitioner. Coma resulting directly from alcohol or drug abuse is
excluded.

the Company will pay the Sum Insured as specified in the Policy Certificate
against this Benefit.
(b)

for any actual or alleged errors, omissions or representations made by any

Medical Practitioner or in any Second Opinion or for any consequences of
actions taken or not taken in reliance thereon.

Blindness
(I)

2.2

(B)

The Company does not assume any liability for and shall not be responsible

3.
3.1
(a)

3.2

Exclusions
Waiting Period
90-Day waiting period
(i)

The Company shall not be liable to make any payment under Benefit 1 in
respect of any Critical Illness, Medical Event or Surgical Procedure whose
signs or symptoms first occur within 90 days of the Policy Period Start Date.

(ii)

This exclusion shall not apply for subsequent Policy Periods provided that
there is no break in insurance cover for that Insured Person and that the
Policy has been renewed with the Company for that Insured Person on
time and for the same or lower Sum Insured.

Permanent Exclusions applicable to Benefit 1

Any claim in respect of any Insured Person for, arising out of or directly or indirectly due to
any of the following shall not be admissible unless expressly stated to the contrary
elsewhere in the Policy Terms and Conditions:

(a)

Any claim with respect to any Critical Illness diagnosed or which manifested prior
to Policy Period Start Date.

(b)

Any congenital illness or condition or inherited disorder.

(c)

Any medical procedure or treatment, which is not medically necessary or not

performed by a Medical Practitioner.

(d)

Any physical, medical or mental condition or treatment or service that is

specifically excluded under the Special Conditions in the Policy Certificate.

(e)

Any treatment relating to birth defects.

4.

Portability

(a)

If the Policyholder and/or Insured Person applies to the Company for a health
insurance policy, and provided that

(f)

Birth control procedures and hormone replacement therapy.

(g)

Any treatment through self-medication or any treatment that is not scientifically

recognized.

3.3

Permanent Exclusions applicable to Benefit 2

modified organisms and chemically synthesized toxins) which are capable

of causing any Illness, incapacitating disablement or death.
(l)

Any treatment arising from or traceable to pregnancy (including voluntary

termination), miscarriage (unless due to an Accident), childbirth, maternity
(including caesarian section), abortion or complications of any of these. This
exclusion will not apply to ectopic pregnancy.

(i)

The proposed Insured Person has been covered without any break under
any health insurance policy from any non-life insurance company
registered with the IRDA; and

Any claim in respect of any Insured Person for, arising out of or directly or indirectly due to
any of the following shall not be admissible unless expressly stated to the contrary
elsewhere in the Policy Terms and Conditions:

(ii) The Sum Insured opted for by the proposed Insured Person with the
Company is equal to or higher than the Sum Insured of the expiring health
insurance policy, then

(a)

the Waiting Periods as defined in Clauses 4.1(a) of this Policy shall be waived to
the extent of the Sum Insured under the expiring health insurance policy.

3.4

Payment of compensation in respect of death, Injury or disablement of Insured

Person directly or indirectly caused by venereal disease or insanity except where
such condition arises directly as a consequence of an Accident during the Policy
Period.
Permanent Exclusions applicable to all Benefits

Any claim in respect of any Insured Person for, arising out of or directly or indirectly due to
any of the following shall not be admissible unless expressly stated to the contrary
elsewhere in the Policy Terms and Conditions:
(a)

Any condition directly or indirectly caused by or associated with any sexually

transmitted disease, including Genital Warts, Syphilis, Gonorrhoea, Genital
Herpes, Chlamydia, Pubic Lice and Trichomoniasis, Acquired Immuno
Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human TCell Lymphotropic Virus Type III (HTLVIII or IITLB-III) or Lymphadinopathy
Associated Virus (LAV) or the mutants derivative or Variations Deficiency
Syndrome or any Syndrome or condition of a similar kind.

(b)

Any Pre-existing Disease or any complication arising therefrom.

(c)

Any mental Illness, stress, psychiatric or psychological disorders.

(d)

Acts of self-destruction or self-inflicted Injury, attempted suicide or suicide

while sane or insane or any Illness or Injury attributable to consumption, use,
misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.

(e)

Participation in any flying activity except as a bonafide fare-paying passenger in

an aircraft that is authorized by the relevant regulations to carry such passengers
between established aerodromes.

(f)

War (whether declared or not) and war like occurrence or invasion, acts of
foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections,
mutiny, military or usurped power, seizure, capture, arrest, restraints and
detainment of all kinds.

(g)

Participation in actual or attempted felony, riots, civil commotion, criminal

misdemeanor;

(h)

Any Illness or Injury directly or indirectly resulting or arising from or

occurring during commission of any breach of any law by the Insured Person
with any criminal intent.

(i)

The Waiting Periods under Clauses 4.1(a) shall be applicable afresh to the
amount by which the Sum Insured under this Policy exceeds the total of Sum
Insured under the terms of the expiring health insurance policy.
(b)

The Waiting Periods as defined in Clauses 4.1(a) shall be applicable individually

for each Insured Person and claims shall be assessed accordingly.

(c)

In case the Policyholder has opted to switch to any other insurer under
Portability and the outcome of acceptance of the Portability is awaited from the
new insurer on the date of Renewal:
(i)

(ii) In case any claim is reported during the extended Policy Period, the
Policyholder shall first pay the premium so as to make the Policy Period of
12 full calendar months. The Company's liability for the payment of the
claim shall commence only once such premium is received.
Note: Portability provisions will apply even if the Insured Person migrates to any other
health insurance policy.

5.

Working in underground mines, tunneling or explosives, or involving electrical

installation with high tension supply, or as jockeys or circus personnel, or
engaged in Hazardous Activities.

(k)

Nuclear, chemical or biological attack or weapons, contributed to, caused by,

resulting from or from any other cause or event contributing concurrently or
in any other sequence to the loss, claim or expense. For the purpose of this
exclusion:
(i)

Nuclear attack or weapons means the use of any nuclear weapon or device
or waste or combustion of nuclear fuel or the emission, discharge,
dispersal, release or escape of fissile/fusion material emitting a level of
radioactivity capable of causing any Illness, incapacitating disablement or
death.

(ii) Chemical attack or weapons means the emission, discharge, dispersal,

release or escape of any solid, liquid or gaseous chemical compound which,
when suitably distributed, is capable of causing any Illness, incapacitating
disablement or death.
(iii) Biological attack or weapons means the emission, discharge, dispersal,
release or escape of any pathogenic (disease producing) microorganisms and/or biologically produced toxins (including genetically

Claims Intimation, Assessment and Management

Upon the occurrence of any event, Illness or Injury that may give rise to a claim under this
Policy, then as a condition precedent to the Company's liability under the Policy, the
Policyholder or Insured Person shall undertake all of the following:
5.1

Intimation

(a)

If any event as covered under this Policy occurs, the Policyholder or Insured
Person or Nominee as the case may be shall notify the claim to the
Company within thirty (30) days from the date of its occurrence either at the
Company's call center or in writing.

(b)

It is agreed and understood that the following details are to be provided to

the Company at the time of intimation of claim:
(i)

Engaging in sporting activities in so far as they involve the training for or

participation in competitions of professional sports.

(j)

The Company may at the request of the Policyholder, extend the Policy
for a period not less than 1 month at an additional premium to be paid on
a pro-rated basis.

Policy Number;

(ii) Name of the Policyholder;

(iii) Name of the Insured Person in respect of whom the claim is made;
(iv) Nature of the event;
(v) Name and address of the attending Medical Practitioner and Hospital, if
applicable;
(vi) Date of admission to Hospital, if applicable;
(vii) Any other information, documentation or details requested by the
Company.
5.2

Claims Documents
The following information and documentation shall be submitted to the
Company at the earliest and in any event within 30 days of occurrence of the
event in respect of all claims:

(a)

General claim documents

(i)

Duly completed and signed claim form, in original.

(ii) Original discharge/death summary from the Hospital;

(iii) Certificate from the attending Medical Practitioner of the Insured
Person confirming, at least the following:

(I)

Name of the Insured Person;

(II)

Name, date of occurrence and medical details.

(iv) Any other information, documentation or details requested by the

Company.
(b)

The Company's Medical Practitioner and representatives shall be given access

and co-operation to inspect the Insured Person's medical and Hospitalization
records and to investigate the facts and examine the Insured Person.

(f)

The Company shall be provided with complete documentation and information

which the Company has requested to establish its liability for the claim, its
circumstances and its quantum.

5.4

Payment Terms

Additional claim documents for Benefit 1

(i)

(c)

(e)

Certificate from the attending Medical Practitioner of the Insured Person

confirming that the claim does not relate to any Pre-Existing Illness or any
Illness or Injury which was diagnosed or existed within the first ninety (90)
days of the Policy Period Start Date.

(a)

All payments under this Policy shall be made in Indian Rupees and within India.

(b)

(ii) Original investigation test reports, indoor case papers and medical
documents as specified under the respective Critical Illness, Covered
Surgical Procedure or Covered Medical Event.

The Company shall have no liability to make payment of a claim under the Policy
in respect of an Insured Person, once the Sum Insured for that Insured Person is
exhausted.

(c)

The Company shall not be liable for any claims which are incurred from the due
date of installment till the date and time of revival of the Policy.

(d)

The Company shall settle any claim within 30 days of receipt of all the necessary
documents/ information as required for settlement of such claim and sought by
the Company. The Company shall provide the Policyholder an offer of
settlement of claim and upon acceptance of such offer by the Policyholder the
Company shall make payment within 7 days from the date of receipt of such
acceptance. In case there is delay in the payment beyond the stipulated timelines,
the Company shall pay additional amount as interest at a rate which is 2% above
the bank rate prevalent at the beginning of the financial year in which the claim is
reviewed by it.

(e)

Additionally in the event of any claim being lodged under the Policy for any
cause whatsoever, all the subsequent premium installments shall immediately
become due and payable notwithstanding anything to the contrary herein above
contained. The Company shall have the right to recover and deduct any or all
the pending installments from the claim amount due under the Policy.

(f)

Claim under Benefit 1 or Benefit 2 can be made only once during the Policy
Period. The claim shall be paid only for the Policy Period in which the event
giving rise to claim under Benefit 1 or Benefit 2 occurs.

6.

General Terms and Conditions

Additional claim documents for Benefit 2

Purpose of Document Category

Indicative List of Documents

Identity Proof

Voter ID, Passport, PAN Card, Driving License, ration card,

Aadhar, or any other proof accepted by the KYC norms as
approved by the Company and which is admissible in court
of law

Address Proof

Voter ID, Passport, Driving License

Age Proof

Voter ID, Passport, PAN Card, Matriculation Pass

Certificate, Driving License, Birth Certificate

Incident Proof

FIR, Panchnama, Final Police Report, State Electricity Board

Report, Factory Inspection Report, Forensic Report, Valid
Passenger Ticket/Boarding Pass of the Common Carrier, or
any other proof to the satisfaction of the Company

Cause of Loss

Viscera Report, Post Mortem Report (if conducted), MLC

report, Medical Report/Certificate stating the cause of death

Disability

Disability Certificate from Government Medical Board, Fitness

Certificate, Medical Prescription

Death

Death Certificate

Claimant Identity

Succession Certificate, Identity Proof of Nominee, legal heirs or

any other proof to the satisfaction of the Company for the
purpose of a valid discharge

Medical Expenses

Hospital Discharge Summary, Bills, Receipts, Medical Practitioner

Certificate, Medical/Clinical /Pathological/Diagnostics Records

Note:
(i) The Company reserves the right to seek additional documents depending upon the cause of claim or the Benefit
under which the claim is made.

6.1

6.2

(ii) Any one of the above documents under each category needs to be provided.

(d)

The Company shall condone delay on merit for delayed claims where delay
is proved to be for reasons beyond the control of the Policyholder or the
Insured Person.

(e)

Only in the event that original bills, receipts, prescriptions, reports or other
documents have already been given to any other insurance company or to a
reimbursement provider the Company will accept properly verified
photocopies of such documents attested by such other insurance
company/reimbursement provider along with an original certificate of the
extent of payment received from such insurance company/reimbursement
provider.

5.3

6.3

(b)

The Insured Person shall follow the directions, advice or guidance provided by a
Medical Practitioner and the Company shall not be obliged to make the payment
that is brought about or contributed to by the Insured Person failing to follow
such directions, advice or guidance.

(c)

Intimation of the claim, Notification of the Claim and submission or provision of

all information and documentation shall be made promptly and in any event in
accordance within time frame specified in Clause 5 of the Policy Terms and
Conditions.

(d)

The Insured Person will, at the request of the Company, submit himself for a
medical examination by the Company's nominated Medical Practitioner as often
as the Company considers reasonable and necessary. The cost of such
examination will be borne by the Company.

Reasonable Care
Insured Persons shall take all reasonable steps to safeguard the interests against
any Illness or Injury that may give rise to a claim.

6.4

Material Change
It is a condition precedent to the Company's liability under the Policy that the
Policyholder shall immediately notify the Company in writing of any material
change in the risk on account of change in nature of occupation or business at his
own expense. The Company may, in its discretion, adjust the scope of cover
and/or the premium paid or payable, accordingly.

Policyholder's or Insured Person's duty at the time of claim

All reasonable steps and measures must be taken to avoid or minimize the
quantum of any claim that may be made under this Policy.

Observance of Terms and Conditions

The due observance and fulfillment of the Terms and Conditions of this Policy
(including the realization of premium by their respective due dates and
compliance with the specified procedure on all claims) in so far as they relate to
anything to be done or complied with by the Policyholder or any Insured Person,
shall be condition precedent to the Company's liability under the Policy.

It is agreed and understood that as a condition precedent for a claim to be

considered under this Policy:
(a)

Disclosure to Information Norm & Fraud

If any untrue or incorrect statements are made or there has been a
misrepresentation, mis-description or non-disclosure of any material particulars
or any material information having been withheld, or if a claim is fraudulently
made or any fraudulent means or devices are used by the Policyholder or the
Insured Person or any one acting on his / their behalf, the Company shall have no
liability to make payment of any claims and the premium paid shall be forfeited
to the Company.

6.5

Records to be maintained
The Policyholder and Insured Person shall keep an accurate record containing all
relevant medical records and shall allow the Company or its representatives to
inspect such records. The Policyholder or Insured Person shall furnish such
information as the Company may require under this Policy at any time during
the Policy Period and up to three years after the Policy Period End Date, or until
final adjustment (if any) and resolution of all claims under this Policy.

6.6

No constructive notice
Any knowledge or information of any circumstance or condition in relation to
the Policyholder or Insured Person which is in possession of the Company other
than that information expressly disclosed in the Proposal Form or otherwise in
writing to the Company, shall not be held to be binding or prejudicially affect the
Company.

6.7

Complete discharge
Payment made by the Company to the Policyholder or the Nominee or the legal
heir of the Policyholder, as the case may be, of any amount under the Policy shall
in all cases be treated as full and final and construe as an effectual discharge in
favor of the Company.

6.8
(a)

(b)

6.9
(a)

(b)

Upto 1 month

75.0%

87.0%

91.0%

Upto 3 months

50.0%

74.0%

82.0%

25.0%

61.5%

73.5%

Wherever there is a decision to be taken by the Insurer, which happens to be at

variance with the Customers proposal, declarations and other such conduct an
opportunity of natural justice shall be provided to him before a decision is taken
on the merit and circumstances of the question.

0.0%

48.5%

64.5%

Upto 15 months

N.A.

24.5%

47.0%

Any and all disputes or differences under or in relation to the validity,

construction, interpretation and effect to this Policy shall be determined by the
Indian Courts and in accordance with Indian law.
Free Look Period
The Policyholder may, within 15 days from the receipt of the Policy document,
return the Policy stating reasons, if the Terms and Conditions are not acceptable
to the Policyholder.

Upto 18 months

N.A.

12.0%

38.5%

Upto 24 months

N.A.

0.0%

30.0%

Upto 30 months

N.A.

N.A.

8.0%

Beyond 30 months

N.A.

N.A.

0.0%

(c)

If no claim has been made under the Policy, the Company will refund the
premium received after deducting proportionate risk premium for the period
on cover, expenses for medical examination (as per the below mentioned grid)
and stamp duty charges. If only part of the risk has commenced, such
proportionate risk premium shall be calculated as commensurate with the risk
covered during such period.
Assure 2
Upto 3 crores Above 3 crores

In case of demise of the Policyholder,

(i)

Where the Policy covers only the Policyholder, this Policy shall stand null
and void from the date and time of demise of the Policy holder.

(ii)

Where the Policy covers other Insured Persons, this Policy shall continue
till the end of Policy Period or next premium due whichever is earlier. If the
other Insured Persons wish to continue with the same Policy, the Company
will renew the Policy subject to the appointment of a Policyholder
provided that:
(I)

Written notice in this regard is given to the Company before the

Policy Period End Date; and

(II)

A person over Age 18 who satisfies the Company's criteria to

become a Policyholder.

Assure 3 & Assure 4

Upto 10 Lacs

Above 10 Lacs

Upto 45 years

Nil

` 1,000

Nil

` 1,000

Nil

` 2,000

` 1,000

` 2,000

56 years & above

` 1,000

` 4,500

` 2,000

` 4,500

It is agreed and understood that this clause cannot be exercised on any Renewal
of this Policy, if the Policy Terms and Conditions remain unchanged.

6.10

Renewal Notice

(a)

This Policy will automatically terminate on the Policy Period End Date. All
Renewal applications should reach the Company on or before the Policy Period
End Date.
The Company may, in its sole discretion, revise the Renewal premium payable
under the Policy provided that revisions to the Renewal premium are in
accordance with the IRDA rules and regulations as applicable from time to time.
The premium payable on Renewal shall be paid to the Company on or before the
Policy Period End Date and in any event before the expiry of the Grace Period.

(c)

The Company will ordinarily not refuse to renew the Policy except on ground of
fraud, moral hazard or misrepresentation or non-co-operation by the Insured.

(d)

The Company reserves the right to carry out underwriting in relation to any
request for increase of the Sum Insured / change of plan at the time of Renewal
of the Policy.
This product may be withdrawn by the Company after due approval from the
IRDA. In case this product is withdrawn by the Company, this Policy can be
renewed under the then prevailing Health Insurance Product or its nearest
substitute approved by IRDA. The Company shall duly intimate the Policyholder
regarding withdrawal of this product and the options available to the
Policyholder at the time of Renewal of this Policy.

6.11

Cancellation/Termination

(a)

The Company may at any time, cancel this Policy on grounds as specified in
Clause 6.1, by giving 15 days' notice in writing to the Policyholder at his last
known address.

(b)

3 Year

Upto 6 months

46 years to 55 years

(e)

2 Year

Upto 12 months

Age/Sum Insured

(b)

1 Year

Policy Disputes

Pre-policy

(c)

Cancellation date up to (x months) from

Policy Period Start Date

Note: The Company's liability in respect of an Insured Person shall cease upon making any refund of premium
under this Policy in accordance with the Terms and Conditions hereof in respect of such an Insured Person and the
benefit in respect of that Insured Person shall forthwith terminate.

6.12

Limitation of Liability

Any claim under this Policy for which the Notification or Intimation of Claim is received 12
calendar months after the event or occurrence giving rise to the claim shall not be
admissible, unless the Policyholder proves to the Company's satisfaction that the delay in
reporting of the claim was for reasons beyond his control.
6.13

Communication

(a)

Any communication meant for the Company must be in writing and be delivered
to its address shown in the Policy Certificate. Any communication meant for the
Policyholder will be sent by the Company to his last known address or the address
as shown in the Policy Certificate.

(b)

All notifications and declarations for the Company must be in writing and sent to
the address specified in the Policy Certificate. Agents are not authorized to
receive notices and declarations on the Company's behalf.

(c)

Notice and instructions will be deemed served 10 days after posting or

immediately upon receipt in the case of hand delivery, facsimile or e-mail.

6.14

Alterations in the Policy

This Policy constitutes the complete contract of insurance. No change or
alteration shall be valid or effective unless approved in writing by the Company,
which approval shall be evidenced by a written endorsement signed and stamped
by the Company.

6.15

Overriding effect of Policy Certificate

In case of any inconsistency in the Terms and Conditions in this Policy vis-a-vis the
information contained in the Policy Certificate, the information contained in the
Policy Certificate shall prevail.

6.16

Electronic Transactions
The Policyholder and Insured Person agrees to adhere to and comply with all such
Terms and Conditions as the Company may prescribe from time to time, and
hereby agrees and confirms that all transactions effected by or through facilities
for conducting remote transactions including the Internet, World Wide Web,
electronic data interchange, call centers, tele-service operations (whether voice,
video, data or combination thereof) or by means of electronic, computer,
automated machines network or through other means of telecommunication,
established by or on behalf of the Company, for and in respect of the Policy or its
terms, or the Company's other products and services, shall constitute legally
binding and valid transactions when done in adherence to and in compliance with
the Company's Terms and Conditions for such facilities, as may be prescribed
from time to time.

The Policyholder may also give 15 days' notice in writing, to the Company, for
the cancellation of this Policy, in which case the Company shall from the date of
receipt of the notice, cancel the Policy and refund the premium for the
unexpired period of this Policy at the short period scales as mentioned below,
provided no claim has been made and full premium has been received under
the Policy.

6.17

Grievances

(a)

The Company has developed proper procedures and effective mechanism to

address complaints, if any of the customers. The Company is committed to
comply with the Regulations, standards which have been set forth in the

Regulations, Circulars issued from time to time in this regard.

(b)

If the Policyholder has a grievance that the Policyholder wishes the Company to
redress, the Policyholder may contact the Company with the details of his
grievance through:
Website : www.religarehealthinsurance.com
E-mail : customerfirst@religarehealthinsurance.com
Contact No.: 1800-200-4488
Fax : 1800-200-6677
Post/Courier : Any branch office or the correspondence address, during normal
business hours

(c)

If the Policyholder is not satisfied with the Company's redressal of the

Policyholder's grievance through one of the above methods, the Policyholder
may contact the Company's Head of Customer Service at:
The Grievance Cell,
Religare Health Insurance Company Limited
GYS Global,
Plot No. A3, A4, A5,
Sector - 125,
Noida, U.P. - 201301

(d)

If the Policyholder is not satisfied with the Company's redressal of the

Policyholder's grievance through one of the above methods, the Policyholder
may approach the nearest Insurance Ombudsman for resolution of the grievance.
The contact details of Ombudsman offices are mentioned below:

Office of the Ombudsmen

Name of the Ombudsmen

AHMEDABAD

Shri P. Ramamoorthy

BHOPAL

BHUBANESHWAR

Shri B. P. Parija

CHANDIGARH

Contact Details

Area of Jurisdiction

Insurance Ombudsman,
Office of the Insurance Ombudsman, 2nd Floor, Ambica House,
Nr. C.U. Shah College, Ashram Road, AHMEDABAD - 380 014.
Tel : 079-27546840, Fax : 079-27546142
E-mail : ins.omb@rediffmail.com

Gujarat , UT of Dadra & Nagar Haveli,

Daman and Diu

Insurance Ombudsman,
Office of the Insurance Ombudsman, Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near New Market,
BHOPAL(M.P.) - 462 023.
Tel : 0755-2569201, Fax : 0755-2769203
E-mail : bimalokpalbhopal@airtelmail.in

Madhya Pradesh & Chhattisgarh

Insurance Ombudsman,
Office of the Insurance Ombudsman, 62, Forest Park,
BHUBANESHWAR - 751 009.
Tel : 0674-2596455, Fax : 0674-2596429
E-mail : ioobbsr@dataone.in

Orissa

Insurance Ombudsman,
Office of the Insurance Ombudsman, S.C.O. No.101-103,
2nd Floor, Batra Building, Sector 17-D, CHANDIGARH - 160 017.
Tel : 0172-2706468, Fax : 0172-2708274
E-mail : ombchd@yahoo.co.in

Punjab , Haryana, Himachal Pradesh,

Jammu & Kashmir , UT of Chandigarh

CHENNAI

Shri V. Ramasaamy

Insurance Ombudsman,
Office of the Insurance Ombudsman, Fathima Akhtar Court,
4th Floor, 453 (old 312), Anna Salai, Teynampet, CHENNAI - 600 018.
Tel : 044-24333668/5284, Fax : 044-24333664
E-mail : chennaiinsuranceombudsman@gmail.com

Tamil Nadu, UT - Pondicherry Town

and Karaikal (which are part of UT of
Pondicherry)

NEW DELHI

Shri Surendra Pal Singh

Insurance Ombudsman,
Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Bldg.,
Asaf Ali Road, NEW DELHI - 110 002.
Tel : 011-23239633, Fax : 011-23230858
E-mail : iobdelraj@rediffmail.com

Delhi & Rajasthan

GUWAHATI

Shri D. C. Choudhury

Insurance Ombudsman,
Office of the Insurance Ombudsman, Jeevan Nivesh, 5th Floor,
Near Panbazar Overbridge, S.S. Road, GUWAHATI - 781 001 (ASSAM).
Tel : 0361-2132204/5, Fax : 0361-2732937
E-mail : ombudsmanghy@rediffmail.com

Assam , Meghalaya, Manipur, Mizoram,

Arunachal Pradesh, Nagaland
and Tripura

HYDERABAD

Shri K. Chandrahas

Insurance Ombudsman,
Office of the Insurance Ombudsman, 6-2-46, 1st Floor, Moin Court,
A.C. Guards, Lakdi-Ka-Pool, HYDERABAD - 500 004.
Tel : 040-65504123, Fax : 040-23376599
E-mail : insombudhyd@gmail.com

Andhra Pradesh, Karnataka and

UT of Yanam - a part of the UT
of Pondicherry

KOCHI

Shri R. Jyothindranathan

Insurance Ombudsman,
Office of the Insurance Ombudsman, 2nd Floor, CC 27/2603,
Pulinat Bldg., Opp. Cochin Shipyard, M.G. Road, ERNAKULAM - 682 015.
Tel : 0484-2358759, Fax : 0484-2359336
E-mail : iokochi@asianetindia.com

Kerala, UT of (a) Lakshadweep,

(b) Mahe - a part of UT
of Pondicherry

KOLKATA

Ms. Manika Datta

Insurance Ombudsman,
Office of the Insurance Ombudsman, 4th Floor,
Hindusthan Bldg. Annexe, 4, C.R.Avenue, Kolkatta - 700 072.
Tel : 033-22124346/(40), Fax : 033-22124341
E-mail : iombsbpa@bsnl.in

West Bengal, Bihar, Jharkhand and

UT of Andeman & Nicobar Islands,
Sikkim

LUCKNOW

Shri G. B. Pande

Insurance Ombudsman,
Office of the Insurance Ombudsman, Jeevan Bhawan, Phase-2,
6th Floor, Nawal Kishore Road, Hazaratganj, LUCKNOW - 226 001.
Tel : 0522-2231331, Fax : 0522-2231310
E-mail : insombudsman@rediffmail.com

Uttar Pradesh and Uttaranchal

MUMBAI

Shri S. Viswanathan

Insurance Ombudsman,
Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W), MUMBAI - 400 054.
Tel : 022-26106928, Fax : 022-26106052
E-mail : ombudsmanmumbai@gmail.com

Maharashtra, Goa

The details of Insurance Ombudsman are available on IRDA website : www.irda.gov.in, on the website of General Insurance Council : www.generalinsurancecouncil.org.in, the Company's website
www.religarehealthinsurance.com or from any of the Company's offices.
Address and contact number of Governing Body of Insurance Council Shri M.V.V. Chalam, Secretary General
3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W),
MUMBAI - 400 021
Tel : 022-26106245
Fax : 022-26106949
E-mail : inscoun@gmail.com

The Secretary
3rd Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz (W),
MUMBAI - 400 021.
Tel : 022 26106980
Fax : 022-26106949

Annexure 1 - List of Critical Illness

S.No.

10

Particulars

Plan Name
Assure 2

Assure 3

Assure 4

Cancer

Yes

Yes

Yes

End Stage Renal Failure

Yes

Yes

Yes

Multiple Sclerosis

Yes

Yes

Yes

Benign Brain Tumour

Yes

Yes

Yes

Total Blindness

Yes

Yes

Yes

Motor Neurone Disorder

Yes

Yes

Yes

End Stage Lung Disease

Yes

Yes

Yes

Major Organ Transplant

Yes

Yes

Yes

Heart Valve Replacement

Yes

Yes

Yes

10

Coronary Artery Bypass Graft

Yes

Yes

Yes

11

Stroke

Yes

Yes

Yes

12

Paralysis

Yes

Yes

Yes

13

Myocardial Infarction

Yes

Yes

Yes

14

Major Burns

Yes

Yes

Yes

15

Coma

Yes

Yes

Yes

16

Parkinson's Disease

No

No

Yes

17

Alzheimer's Disease

No

No

Yes

18

End Stage Liver Disease

No

No

Yes

19

Bacterial Meningitis

No

No

Yes

20

Aplastic Anaemia

No

No

Yes

Add-on Benefits
1.

The Add-on Benefits shall be available only if the same is specifically mentioned in
the Policy Certificate.

2.

The Add-on Benefits are subject to the terms and conditions stated below and the
Policy Terms & Conditions.

3.

Add-on Benefit 1: Everyday Care

3.1

Definition :
For the purpose of this Add-on Benefit :
Deductible:
A Deductible is a cost-sharing requirement under this Add-on Benefit that
provides that the Company will not be liable for a specified rupee amount of the
covered expenses, which will apply before any benefits are payable by the
Company. A deductible does not reduce the Sum Insured.

(a)

(b)

Everyday Care Services :

The Company will provide the following Everyday Care Services (the Services)
under this Add-on Benefit to the Insured Person during the Policy Period:
(i)
Health Care Services which include only the following :

(ii)

I.

Doctor Anytime /Free Health Helpline: The Insured Person may seek
medical advice from a Medical Practitioner through the telephonic or
on online mode by contacting the Company on the helpline details
specified on the Company's website;

II.

Health Portal: The Insured Person may access health related

information and services available through the Company's website;

III.

Health & Wellness Offers: The Insured Person may avail discounts on
the health and wellness products and services listed on the
Company's website through the Network Service Provider.

Doctor consultations:
I.
The Insured Person may consult a Medical Practitioner within the
Company's Network, on payment of `100 per consultation.
II.

(c)

Maximum 4 consultations in a Policy Year are permissible for the

same Illness or Injury.

Service Provider means any person, organization, institution that has been
empanelled with the Company to provide Services specified under this Add-on
Benefit to the Insured Person.

obtained under this Add-on Benefit, then whether or not to act on the
advice/information received and/or use the Services obtained.
(f)

These Services are for additional information purposes only and do not and
should not be deemed to substitute the Insured Person's visit/ consultation to an
independent Medical Practitioner.

(g)

The Company does not make any representation as to the adequacy or accuracy
of the Services, the Insured Person's or any other person's reliance on the same
or the use to which the Services are put. The Company does not assume any
liability for and shall not be responsible for any actual or alleged errors, omissions
or representations made by any Medical Practitioner or Service Provider or for
any consequences of actions taken or not taken in reliance thereon.

(h)

The Insured Person understands and agrees that although the confidentiality of
the information provided by him shall be maintained however the calls made by
him shall be recorded for the purposes of quality and for maintaining the record
of their health information.

3.4

Cancellation

(a)

The Policyholder may give 15 days' notice in writing, to the Company, for the
cancellation of this Add-on Benefit, in which case the Company shall from the date
of receipt of the notice, cancel this Add-on Benefit and refund the premium for
the unexpired period at the short period scales, as mentioned below, provided
that the Insured Person has not utilized any of the Everyday Care Services
specified in Clause 3.1(b) of this Add-on Benefit.

(b)

Refund % to be applied on annual premium rates

Cancellation date up to (x months) from

Policy Period Start Date

1 Year

2 Year

3 Year

Upto 1 month

75.0%

87.0%

91.0%

Upto 3 months

50.0%

74.0%

82.0%

Upto 6 months

25.0%

61.5%

73.5%

Upto 12 months

0.0%

48.5%

64.5%

Upto 15 months

N.A.

24.5%

47.0%

Upto 18 months

N.A.

12.0%

38.5%

(d)

Clause 4.3(a)(xx) of the Policy Terms & Conditions is superseded only to the
extent expressly specified in this Add-on Benefit.

Upto 24 months

N.A.

0.0%

30.0%

3.2

Claim Process applicable to this Add-on Benefit.

Upto 30 months

N.A.

N.A.

8.0%

(a)

If the Service is being availed in person, the Insured Person shall present his
unique identification number along with a valid identification document (Voter
ID card/driving license/passport/PAN card/any other identity proof as
approved by the Company) to the Service Provider and pay `100 per
consultation (in case of Doctor Consultation as specified under Clause
3.1(b)(ii)) prior to availing such Services.

Beyond 30 months

N.A.

N.A.

0.0%

The Service Provider will provide the Services only after validation and authorization of the
unique identification number by the Company.
(b)

If the Services are availed over the telephone or through online mode, the Insured
Person will be required to provide the details as sought by the Company/ Service
Provider in order to establish authenticity and validity prior to availing such
Services.

(c)

If the Services are availed through the discount/redeemable voucher provided by

the Company, the Insured Person shall present the discount/redeemable voucher
along with a valid identification document (Voter ID card/ driving license/
passport/PAN card/ any other identity proof as approved by the Company) to
the Service Provider prior to availing such Services.

3.3

General Terms & Conditions

(a)

If the Policyholder opts for this Add-on Benefit during the Policy Period, the
expiry of this Add-on Benefit would coincide with the Policy Period End Date.

(b)

It is agreed and understood that the Company may, at its sole discretion, modify
the list of Service Providers, Medical Practitioners or Health & Wellness Offers..

(c)

The rate of discount and the name of Service Provider offering the Services can
be obtained either through Company's website or from the Company's call
centre. Before availing the Services, the Policyholder or Insured Person may check
the updated details of the available Service Providers and the applicable
discounts/services from the Company's website or call centre.

(d)

The list of Services and discounts offered may vary with location and may be time
barred and/or may change depending upon availability of Service Providers and
discounts/Services available at such locations.

(e)

The Insured Person is free to choose whether to obtain the Services and, if

(c)

If any of the Everyday Care Services specified in Clause 3.1(b) of this Add-on
Benefit has been utilized and the Policyholder chooses to cancel this Add-on
Benefit then Company shall not be liable to refund any premium paid in
respect to this Add-on Benefit.

4.

Add-on Benefit 2 : HIV Cover

4.1

Benefit:
If, during the Policy Period, an Insured Person is first diagnosed to be suffering
from an HIV Infection, then the Company will pay the Sum Insured mentioned
against this Add-on Benefit and the benefits under this Add-on Benefit shall be
terminated for that Insured Person provided that, the HIV Infection is caused by
any of the reasons other than as specified below :

(a)

(i)

Parent to child transmission.

(ii)

Transmission through unprotected sex (Heterosexual, Homosexual or

Bisexual)

For the purposes of this Add-on Benefit, HIV Infection means a positive HIV
antibody testing (rapid or laboratory-based enzyme immunoassay). This is usually
confirmed by a second HIV antibody test (rapid or laboratory-based enzyme
immunoassay) relying on different antigens or of different operating c
characteristics.
and /or;
a positive virological test for HIV or its components (HIV-RNA or HIV-DNA or
ultrasensitive HIV p24 antigen) confirmed by a second virological test obtained
from a separate determination.

(b)

The coverage under the Policy for other Benefits for that Insured Person shall
continue under this Policy.

4.2

Exclusions

(a)

Waiting Period
90-Day waiting period

11

The Company shall not be liable to make any payment under this Add-on
Benefit in respect of any HIV infection whose signs or symptoms, first occur within
90 days of the Policy Period Start Date.
(b)

Permanent Exclusions

4.4

General Terms and Conditions

(a)

If the Policyholder opts for this Add-on Benefit during the Policy Period, the
expiry of this Add-on Benefit would coincide with the Policy Period End Date.

(b)

Admissibility of a Claim under this Add-on Benefit is independent and mutually

exclusive to admissibility of any Claim under Benefit 1 or Benefit 2 and the event
giving rise to the Claim shall be within the Policy Period for the Claim to be
accepted.

(c)

The maximum, total and cumulative liability of the Company for an Insured
Person for any and all Claims incurred under this Add-on Benefit during the Policy
Year in relation to any Insured Person shall not exceed the Sum Insured under this
Add-on Benefit for that Insured Person.

(d)

Cancellation

(i) Any Claim in respect of any Insured Person for, arising out of or directly or
indirectly due to any of the following shall not be admissible unless expressly
stated to the contrary elsewhere in the Policy terms and conditions:

4.3
(a)

(I)

Any Claim with respect to an HIV infection detected, diagnosed or

which manifested prior to Policy Period Start Date or after the Policy
Period End Date.

(II)

Any congenital illness or condition or inherited disorder.

(III)

Detection of HIV infection other than by an Accident.

Claim Process

(ii) It is agreed and understood that the following details are to be provided to
the Company at the time of intimation of Claim:

Refund % to be applied on annual premium rates

1 Year

Upto 1 month

75.0%

2 Year

3 Year

(I)

Policy Number;
Name of the Policyholder;

Upto 3 months

50.0%

74.0%

82.0%

(III)

Name of the Insured Person in respect of whom the Claim is made;

Upto 6 months

25.0%

61.5%

73.5%

Upto 12 months

0.0%

48.5%

64.5%

(IV) Nature of the event;

i

Name and address of the attending Medical Practitioner and Hospital,

f applicable;

(VI) Date of diagnosis of HIV infection;

(VII) Any other information, documentation or details requested by the
Company.
(iii) The Policyholder / Insured person is required to intimate to the Company for
Claim if any event as covered under this Policy occurs.

(i) Duly completed and signed claim form, in original.

(ii) Certificate from the attending Medical Practitioner of the Insured Person
confirming, at least the following:
(I)

Name of the Insured Person;

(II)

Name, date of occurrence and medical details.

(iii) Certificate from the attending Medical Practitioner of the Insured Person
confirming that the Claim does not relate to any Pre-Existing Illness or any
Illness or Injury which was diagnosed or existed within the first ninety (90)
days of the Policy Period Start Date.
(iv) Original investigation test reports, indoor case papers and medical
documents as specified under the respective Critical Illness, Covered Surgical
Procedure or Covered Medical Event.
(v) Any other information, documentation or details requested by the
Company.
(vi) Only in the event that the original bills, receipts, prescriptions, reports or
other documents have already been given to any other insurance company
or to a reimbursement provider the Company will accept properly verified
photocopies of such documents attested by such other insurance
company/reimbursement provider along with an original certificate of the
extent of payment received from such insurance company/reimbursements
provider.
Payment Terms
(i)

All payments under this Add-on Benefit shall be made in Indian Rupees
and within India.

(ii)

The Company shall have no liability to make payment of a Claim under

this Add-on Benefit in respect of an Insured Person, once the Sum
Insured under this Add-on Benefit for that Insured Person is
exhausted or the Policy gets terminated before the first diagnosis of
HIV Infection.

87.0%

91.0%

Upto 15 months

N.A.

24.5%

47.0%

Upto 18 months

N.A.

12.0%

38.5%

Upto 24 months

N.A.

0.0%

30.0%

Upto 30 months

N.A.

N.A.

8.0%

Beyond 30 months

N.A.

N.A.

0.0%

(iii)

If any Claim has been made under this Add-on Benefit and the Policyholder
chooses to cancel this Add-on Benefit, then Company shall not be liable to
refund any premium paid in respect to this Add-on Benefit.

(iv)

If this Add-on Benefit is cancelled at the Policyholder's request, then no

Claim shall be admissible under this Add-on Benefit subsequently.

Claim Documents
The following information and documentation shall be submitted to the
Company at the earliest and in any event within 30 days of occurrence of the
event in respect of all Claims:

12

(ii)

Cancellation date up to (x months) from

Policy Period Start Date

(II)

(V)

(c)

The Policyholder may give 15 days' notice in writing, to the Company, for
the cancellation of this Add-on Benefit, in which case the Company shall
from the date of receipt of the notice, cancel this Add-on Benefit and
refund the premium for the unexpired period at the short period scales, as
mentioned below, provided that the Insured Person has not made any
Claim under this Add-on Benefit.

Intimation
(i) If an event as covered under this Add-on Benefit occurs, the Policyholder or
Insured Person or Nominee as the case may be shall notify the Claim to the
Company within thirty (30) days from the date of its occurrence either at the
Company's call center or in writing.

(b)

(i)